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Ten ways your practice can address inequality

From making it easier to register to prescribing painting and decorating classes, there are many things practices can do to help the disadvantaged gain equal access to healthcare. Dr Angela Jones gives some tips

From making it easier to register to prescribing painting and decorating classes, there are many things practices can do to help the disadvantaged gain equal access to healthcare. Dr Angela Jones gives some tips

The shocking health disparities between the most and least advantaged in society are largely socially determined, but that doesn't mean GPs cannot play a big part in addressing them. Indeed, we already do – without our system of primary care, the situation would be much worse.

To do better at reducing inequality, GPs need to go the extra mile. Here are 10 suggestions for what practices can do to make a real difference. They get increasingly radical but even if I lose you by the end, hopefully you'll feel some are worth implementing.

1 Make it easy for patients to register with your practice

There is no point having a universal health service if those in most need of care do not have access. Registration policies that require proofs of identity or address, or disclosure of health conditions prior to acceptance, discriminate against people with long-term conditions and those who are in insecure accommodation or homeless, and discourage these groups from presenting to primary care.

2 Train doctors to be inclusive

Many practices are involved in undergraduate or postgraduate training. The impact, for good or for bad, of the attitudes adopted at the practice during training cannot be underestimated. GPs have a huge opportunity to demonstrate good practice in the care of people with complex health and social problems, both in terms of respectful attitude, positive, patient-centred consulting styles and practical problem-solving, helping to ensure the next generation of clinicians can develop the skills of inclusive practice.

3 Beware of ‘diagnostic overshadowing'

I only recently came across this term, but I love it. It was originally developed to describe the tendency to overlook mental health problems in people with a known intellectual disability, but it explains so well what can go wrong when a patient is diagnosed with one problem – leaving them vulnerable to misdiagnosis should they present with something else. So the harmful drinker who presents with epigastric pain, which is attributed to alcoholic gastritis but is actually due to angina, or the chronically depressed person whose hypothyroidism goes undetected for months or years, has lost out because of an overlap in symptoms – and this exacerbates health inequity.

4 Offer a friendly, welcoming and respectful reception desk

The quality of care and service offered by reception staff is a key factor in engaging people in healthcare. I know intelligent and motivated people who shy away from attending their GP surgery because they find the receptionists unfriendly, invasive in their questioning and not mindful of their privacy. Practices that take a respectful approach to patients can engage even the most challenging, contributing to the wellbeing of all and reducing difficult behaviour and untoward incidents in the surgery.

5 Don't complain to the practice manager when a receptionist takes on a difficult patient

I've done it myself: ‘Why, oh why, did we take this one on?' It's a normal despairing reaction to being confronted by a patient with a seemingly insoluble constellation of health and social needs, who will absorb a huge amount of time and effort and for whom there is no obvious pathway to obtaining support for their problems. But taking this frustration out on the reception staff is unacceptable and counterproductive. Are you sure there is nothing out there for your patient, or is it that you do not know enough about local services?

6 Keep an up-to-date file of local resources

Many areas have resource guides – in my area, it's the Mind Guide to Mental Health Services, which is more thumbed than the BNF. It is a treasure trove of addresses, telephone numbers and emails for the local statutory and third-sector agencies offering support for a huge range of needs. Commendably, it includes resources for the physically as well as mentally and intellectually disabled, and is updated roughly every year. Even so, there are numerous additions and corrections scribbled in, as new things are started up and contact details change. A universally accessible and searchable online resource for this kind of information would be ideal, but until then there's Google. Googling during the consultation can be a positive experience – a print-out of a map and access details to a local agency are often more helpful than a prescription.

7 Develop formal links with outside agencies

Colocating advisers from outside the NHS into primary care can be beneficial on a number of levels. Easy access to advice around social determinants of ill health such as housing, benefits, employment, volunteering and so on not only reduces the effort required by the patient to access services but also the effort required by the GP to get them there. There may also be opportunities for funding these facilities, such as sharing reception costs or room rental. Even without such inducements, the potential for reduction in workload and frustration should be enough to give this a try.

8 Develop social prescribing options

Exercise on prescription is available in many areas, although it can be relatively inflexible and somewhat tokenistic. Why not lobby your PCT or practice-based commissioning group for a more comprehensive offer? What about gardening groups, conservation volunteers, painting and decorating, furniture or bicycle repairs, art, music, yoga or dance classes? There is so much that can be done in our communities, and so many people who would benefit from doing it. GPs have the opportunity and the community profile to initiate and support such efforts and many are already doing so. Setting one up as a social enterprise can attract seed funding from various local and national agencies.

9 Get involved with community development

GPs are in an excellent position to know and understand the problems of the communities they serve. They are also in a position to know who the most resourceful and resilient people are in the community, and to encourage those people to get together and think about how to address their problems themselves.

Top-down initiatives often result in widening rather than closing the gap in healthcare and opportunity. Whereas bottom-up solutions, tailored to the needs of a locality, have the potential to make a sustained impact.

The support of the local primary care team can be invaluable in solving the problems of its patients and can have positive effects on the health and wellbeing of a community.

10 Take patient participation further...

Many practices have patient groups, but the extent to which patients are involved in the running of the practice is hugely variable. Imagine a world where every GP practice ran on the principles of social enterprise– an organisation with a social mission that routinely involves its patients in decisions regarding the running of the business. Radical maybe, but not impossible. It could offer an ethical, accountable method for ensuring the financial benefits of achieving targets were fairly distributed across staff teams and that the community also benefited from its part in the process by spending some of the funds on improving access to other healthcare interventions.

Dr Angela Jones is chair of the RCGP's health inequalities standing group and a sessional GP in Oxford and Westminster

Ten ways your practice can address inequality Ten ways your practice can address inequality

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